HIV Prevention for Hard-to-Reach Men Who Have Sex with Men

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Men who have sex with men (MSM) are a priority for HIV prevention in all parts of the world. Recent studies show that globally, MSM are at significantly greater risk for HIV infection than other adults of reproductive age, due to biological, behavioral and structural factors, such as unprotected anal intercourse, multiple sex partners, and the social marginalization and discrimination MSM often endure. Research indicates that MSM are vulnerable regardless of national HIV prevalence levels. Even in areas of medium to high prevalence such as parts of Asia and sub-Saharan Africa, MSM are on average more than nine times more vulnerable to infection than the general population¹.

The term “men who have sex with men” or “MSM” was originally used by epidemiologists and other researchers to distinguish this group by virtue of sexual behavior alone and thus to avoid the more complicated social, political and legal contexts that typically surround sexual identity. It is important to recognize that this term describes behavior alone and that the behavior may not be exclusive. Men who engage in sex with other men may have sexual relationships with women. Same-sex sexual behavior may also be contextual, as for example, during adolescence, while in prison, or when traveling away from home.

While there has been considerable research on HIV prevention for MSM, the bulk of it has focused on MSM in industrialized countries where same-sex sexual behavior is typically not criminalized and where sexual minorities have often organized to protect their interests. Similarly, most of the small but growing body of research on MSM in developing countries has focused on those men who associate their same-sex behavior with an identity. Some MSM in developing countries use the western term “gay” to describe themselves, or a local term that reflects specific cultural ideas about sexual roles or identity. The use of such identity labels facilitates the participation of these men as research subjects and as targeted recipients of HIV-related services, when available.

Most MSM in developing countries; however, are not easily identified as MSM and consequently may not receive targeted services that address their particular needs. According to a UNAIDS estimate in 2006, fewer than five percent of MSM around the world who need such services have access to them².  Contributing to this neglect is the fact that, in many places, same-sex sexual behavior is criminalized or otherwise stigmatized. Furthermore, difficulty identifying MSM prevents accurate estimation of the total population of men engaging in sexual behavior with other men. Surveys seldom include questions about MSM, and researchers are often discouraged from seeking data on this population due to its marginalized status. Consequently, limited available data likely underestimate the prevalence of MSM in a given country.

As the HIV prevention needs of MSM in a variety of epidemic settings become better understood, effective interventions targeting MSM have the potential to reduce the number of new HIV infections among MSM and their sexual partners, both male and female. The challenge of ensuring appropriate and effective HIV prevention support for hard-to-reach MSM” represents an emerging and urgent priority for HIV prevention around the world. Resources presented here help frame the problem, identify some of the challenges for program design, and provide other selected resources for program managers.

Researchers, policy makers, and advocates are working to increase attention to the vulnerability of MSM to HIV. This environment offers an unprecedented opportunity to address the invisibility of MSM within the response to HIV and AIDS, particularly in those places most affected by the epidemic. It is essential to include behavioral surveillance of MSM in national HIV surveillance plans, along with better social science research, to build a robust evidence base that informs funding and program design decisions. Successful programs must address behavioral risk reduction and reach MSM in ways that reflect the diversity of their sexual behavior and the varied social and political contexts in which their behavior takes place. Programs will be further strengthened by efforts to secure legal protections for sexual minorities and to address the stigma and discrimination they often face. As HIV and AIDS interventions around the world increasingly reach MSM who self-identify as members of visible social communities, hard-to-reach MSM, who by contrast defy easy identification, present an urgent challenge to effective program design and implementation.

¹ Baral S., Sifakis F., Cleghorn F., Beyrer C., “Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000–2006: A systematic review,” PLoS (2007), Medicine 4(12): e339. doi:10.1371/journal.pmed.0040339

² Global AIDS epidemic. UNAIDS. Report, (2006).

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